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Winkler E, Wu D, Gil E, McCoy D, Narsinh K, Sun Z, Mueller K, Ross J, Kim H, Weinsheimer S, Berger M, Nowakowski T, Lim D, Abla A, Cooke D. Endoluminal Biopsy for Molecular Profiling of Human Brain Vascular Malformations. Neurology 2022; 98:e1637-e1647. [PMID: 35145012 PMCID: PMC9052570 DOI: 10.1212/wnl.0000000000200109] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 01/11/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Ras-mitogen-activated protein kinase (MAPK) signaling abnormalities occur in most brain arteriovenous malformations (bAVMs). No means exist to molecularly profile bAVMs without open surgery, limiting precision medicine approaches to treatment. Here, we report use of endoluminal biopsy of the vessel lumen of bAVMs to characterize gene expression and blood flow-mediated transcriptional changes in living patients. METHODS Endoluminal biopsy and computational fluid dynamic modeling (CFD) were performed in adults with unruptured AVMs with cerebral angiography. Each patient underwent surgical resection and cell sampling from a contiguous arterial segment. Fluorescence-assisted cell sorting enriched endothelial cells, which were sequenced on an Illumina HiSeq 4000 sequencer. Gene expression was quantified with RNA sequencing (RNAseq). Differential gene expression, ontology, and correlative analyses were performed. Results were validated with quantitative reverse transcription PCR (RT-qPCR). RESULTS Endoluminal biopsy was successful in 4 patients without complication. Endoluminal biopsy yielded 269.0 ± 79.9 cells per biopsy (control 309.2 ± 86.6 cells, bAVM 228.8 ± 133.4 cells). RNAseq identified 106 differentially expressed genes (DEGs) in bAVMs (false discovery rate ≤0.05). DEGs were enriched for bAVM pathogenic cascades, including Ras-MAPK signaling (p < 0.05), and confirmed with RT-qPCR and a panel predictive of MAPK/extracellular signal-regulated kinase inhibitor response. Compared to patient-matched surgically excised tissues, endoluminal biopsy detected 83.3% of genes, and genome-wide expression strongly correlated (Pearson r = 0.77). Wall shear stress measured by CFD correlated with inflammatory pathway upregulation. Comparison of pre-embolization and postembolization samples confirmed flow-mediated gene expression changes. DISCUSSION Endoluminal biopsy allows molecular profiling of bAVMs in living patients. Gene expression profiles are similar to those of tissues acquired with open surgery and identify potentially targetable Ras-MAPK signaling abnormalities in bAVMs. Integration with CFD allows determination of flow-mediated transcriptomic alterations. Endoluminal biopsy may help facilitate trials of precision medicine approaches to bAVMs in humans.
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Affiliation(s)
- Ethan Winkler
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - David Wu
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Eugene Gil
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - David McCoy
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Kazim Narsinh
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Zhengda Sun
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Kerstin Mueller
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Jayden Ross
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Helen Kim
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Shantel Weinsheimer
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Mitchel Berger
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Tomasz Nowakowski
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Daniel Lim
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Adib Abla
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
| | - Daniel Cooke
- From the Department of Neurological Surgery (E.W., D.W., E.G., J.R., M.B., D.L., A.A.), Department of Radiology and Biomedical Imaging (D.M., K.N., Z.S., D.C.), Center for Cerebrovascular Research (H.K., S.W.), Department of Psychiatry (T.N.), Department of Behavioral Sciences (T.N.), and Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research (T.N., D.L.), University of California San Francisco; Siemens Medical Solutions Inc (K.M.), Malvern, PA; and Department of Anatomy (J.R., T.N.), University of California San Francisco, Chan Zuckerberg Biohub
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De Leacy R, Ansari SA, Schirmer CM, Cooke DL, Prestigiacomo CJ, Bulsara KR, Hetts SW. Endovascular treatment in the multimodality management of brain arteriovenous malformations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee. J Neurointerv Surg 2022; 14:1118-1124. [PMID: 35414599 DOI: 10.1136/neurintsurg-2021-018632] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The purpose of this review is to summarize the data available for the role of angiography and embolization in the comprehensive multidisciplinary management of brain arteriovenous malformations (AVMs METHODS: We performed a structured literature review for studies examining the indications, efficacy, and outcomes for patients undergoing endovascular therapy in the context of brain AVM management. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The multidisciplinary evaluation and treatment of brain AVMs continues to evolve. Recommendations include: (1) Digital subtraction catheter cerebral angiography (DSA)-including 2D, 3D, and reformatted cross-sectional views when appropriate-is recommended in the pre-treatment assessment of cerebral AVMs. (I, B-NR) . (2) It is recommended that endovascular embolization of cerebral arteriovenous malformations be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure. (I, B-NR) . (3) Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity. (IIa, B-NR) . (4) The role of primary curative embolization of cerebral arteriovenous malformations is uncertain, particularly as compared with microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence. (III equivocal, C-LD) . (5) Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage. (IIb, C-LD) . (6) Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible. (IIb, B-NR) . (7) The role of AVM embolization as an adjunct to radiosurgery is not well-established. Further research is needed. (III equivocal, C-LD) . (8) Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and/or clinical findings. (I, C-LD) . (9) Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition. (I, C-EO) . CONCLUSIONS Although the quality of evidence is lower than for more common conditions subjected to multiple randomized controlled trials, endovascular therapy has an important role in the management of brain AVMs. Prospective studies are needed to strengthen the data supporting these recommendations.
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Affiliation(s)
- Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sameer A Ansari
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Daniel L Cooke
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | | | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Steven W Hetts
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
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